Healthcare Provider Details

I. General information

NPI: 1023524196
Provider Name (Legal Business Name): CASEY JOE SMITH FNPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2017
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 S 950 W
HEYBURN ID
83336-9765
US

IV. Provider business mailing address

312 S 950 W
HEYBURN ID
83336-9765
US

V. Phone/Fax

Practice location:
  • Phone: 801-484-4479
  • Fax: 844-965-9279
Mailing address:
  • Phone: 801-564-4479
  • Fax: 844-965-9279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number70138
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: